Biomedical Research

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Research Article - Biomedical Research (2017) Volume 28, Issue 19

The comparative analysis of three different mini-invasive methods for upper ureteric calculi which is bigger than 12 mm

Abstract

Objective: To compare the differences of clinical effect and complications of Percutaneous Nephrostolithotomy (PCNL), Ureteroscopic Pneumatic Lithotripsy (UPL) and Ureteroscopic Holmium Laser Lithotripsy (UHLL) in the treatment of upper ureteric calculi which is bigger than 12 mm.

Methods: Totally 196 patients with upper ureteric calculi which is bigger than 12 mm in our hospital were selected as research object from May 1, 2012 to April 30, 2012, and divided into PCNL group (66 cases), UPC group (65 cases) and UHLL group (65 cases) according to the operation method. The condition of operation, postoperative complications, stone expulsion rate and recurrence rate between the three groups were compared.

Results: The operation time of PCNL group was significantly less than that in UPL group and UHLL group (40.9 ± 12.5 vs. 55.1 ± 13.2 vs. 50.7 ± 10.1, P<0.05); the hospital stays were significantly longer than that in UPL group and UHLL group (4.7 ± 1.3 vs. 3.2 ± 0.6 vs. 2.8 ± 0.4, P<0.05); the decline of intraoperative hemoglobin was significantly larger than that in UPL group and UHLL group (2.9 ± 0.7 vs. 1.3 ± 0.5 vs. 1.2 ± 0.7, P<0.05); the successful lithotriptic rates of PCNL group, UPL group and UHLL group were 100.00% (66/66), 89.23% (58/65), 92.31% (60/65) respectively. The stone expulsion rate of PCNL group was significantly higher than that of UPL group and UHLL group (P<0.05). There was no significant difference in total incidence of complications between three groups (P>0.05).

Conclusion: Three methods for upper ureteric calculi which is bigger than 12 mm are well effective. Comparing with UPL and UHLL, PCNL has the advantage of short operation time and hospital stays, as well as better effect on lithotripsy and expulsion, which is recommended adopting in clinical.

Keywords

Mini-invasive, PCNL, UPL, UHLL, Upper ureteric, Calculi.

Introduction

Urological calculi is one of common diseases, frequentlyoccurring
diseases in urology, which can be divided into upper
urinary tract calculi and lower urinary tract calculi. Upper
ureteric calculi are a kind of particular upper urinary tract
calculi [1]. Irregularly shaped calculi, a long interval of
incarceration and inflammatory tissues encapsulation may
occur in calculi which are bigger than 12 mm [2]. The
conservative treatment of big-diameter calculi in upper urinary
tract often has the difficulty to achieve excellent curative
effect. The treatment of minimally invasive surgery is also
relatively difficult. In the past, the treatment of open surgery
had been adopted widely [3,4]. In recent years, it has inclined
to laparoscopic minimal invasive treatment for complex upper
urinary tract calculi over 12 mm with the development of
urological minimal invasive equipment and minimal invasive
surgical technique [5]. At present, the common minimally
invasive surgeries in the treatment of upper urinary tract calculi
clinically are as follows: PCNL (Percutaneous
Nephrolithotomy), UPL (Ureteroscopic Pneumatic
Lithotripsy), and UHLL (Ureteroscopic Holmium Laser
Lithotripsy).

PCNL usually under straight sight fragments the stones via
percutaneous channel not ureter, with the advantages of further
dealing with kidney stones [6]. Generally, UPL under the
ureteroscope takes the advantage of lithotriptor to cause the
fragmentation of the upper ureteric calculi without heat injury
of ureteral mucosa [7]. While UHLL adopts the holmium laser
to fragments the stones, it would hardly produce oddments [8].
Clinically, the three surgical methods have different operative
characteristics with well efficacy almost, and exists the
differences of efficacy at certain extent [9,10].

With regard to the selection of the above surgical techniques,
there are different controversies in clinical [11,12]. Therefore
the research collected 196 patients with upper ureteric calculi
over 12 mm who were treated by PCNL. UPL and UHLL in
our hospital from May 1, 2012 to April 30, 2012. The
difference of each clinical efficacy, complication and
recurrence rate were compared and analysed. The valuable information about the treatment of calculi which is bigger than
12 mm is provided. Now the report is as follows.

Materials and Methods

General information

196 patients with upper ureteric calculi over 12 mm who come
to our hospital were selected as research object from May 1,
2012 to April 30, 2012, of which 124 males and 72 females.
All of patients were informed consent. The ethical committee
of Central Hospital in Jin Hua city Zhe Jiang Province
approved this study (approval no.JH20120042). The average
age is 40.5 ± 7.7 y, ranging from 22 to 58 y. 36 cases are
complicated with underlying diseases of hypertension,
diabetes, coronary and so on. The average largest diameter of
calculi is 17.2 ± 3.6 mm, ranging from 12.0 to 24.3 mm. The
average stay time of calculi within the body is 24.6 ± 4.3 w,
ranging from 13 to 27 w. 196 patients are registered and
numbered respectively according to the order of admission,
and divided into the group of PCNL (66 cases), the group of
UPC (65 cases) and the group of UHLL (65 cases) according
to the operation methods. There were no significant difference
of general information such as gender, age, underlying diseases
and the largest diameter of calculi etc. in patients among three
groups (P>0.05). Inclusion criteria include as follows: the
acceptance of endoscopic calculus operation for the first time
with ≥ 12 mm calculi, no psychiatric disorders, malignant
tumor and other severe underlying diseases, having better
compliance and cooperation, and acceptance of postoperative
follow-up.

Surgical techniques

All cases of three groups are treated by combined spinalepidural
and continuous epidural anesthesia. The operations are
performed by the same doctor or with the assistance of the
doctor’s guidance. The surgeries were completed by using
equipment like Germany Olympus ureteroscopic, Swiss EMS
pneumatic lithotripsy system, American Lumenis holmium
laser system and so on.

Patients with PCNL were placed in lithotomy position.
Ureteral catheter was inserted conversely into the upper ureter
after anesthetizing successfully. Change the posture to prone
position after inserting catheters. Through B-ultrasonic
examination, the position of stones was measured precisely.
Puncture points were 11th intercostal space, lines of shoulder
blades near to spine. Puncture with an 18 gauge puncture
needle of kidney and place zebra urological guidewire. Fascia
was expanded to F16 catheter through fascia dilators
progressively. Place Germany Olympus ureteroscopic, and
ensure that each channel of ureter is smooth. Lithotripsy and
wash were performed directly. The stone of which the diameter
is less than extraction of stone channel was ejected directly.
The wide fragments of calculi were pulled out. The URL
position was turned into lithotomy position. Germany Olympus
ureteroscopic was placed after anesthetizing successfully.
Ureteral catheter was inserted conversely. The stones were localized under the ureteroscopy vision, place Swiss EMS
pneumatic lithotripsy trigger. Lithotripsy and wash were
performed. The tiny fragments of stone were ejected directly.
The wide fragments of calculi were pulled out. The UHLL
position and the establishment method of working aisle are
similar with URL group. Germany Olympus ureteroscopic is
placed after anesthetizing successfully. Lithotripsy is
performed by sheathing the holmium laser fiber with the help
of ureteroscopic. Clear and flush the stones. Meanwhile
patients combined with polyp were dealt. The patients of the
three groups received DJ catheter and three cavities urinary
catheter, and were given with conventional anti-infection
treatment.

Observational indicators and evaluation

Operation time, hospital stays, decline of hemoglobin and
bleeding volume during the operation, the successful
lithotripsy rate and complication of the patients in three groups
were observed and recorded. The patients of three groups were
followed up for 6 months, and by the methods of clinic, phone,
home visit and so on. The occurrence of complication, stone
discharge rate after lithotripsy and relapse rate of stones were
recorded during the follow-up.

Statistical methods

Statistical software SPSS 19.0 was used for data analysis. The
measurement data were expressed as mean ± standard
deviation (x̄ ± s). The comparisons of three groups adopted
single-factor analysis of variance, comparisons between two
groups were performed by SNK-q test. The enumeration data
were analysed by χ2 test. P<0.05 mean that the difference had
statistical significance.

Results

Comparison of 3 groups’ general data

There were no significant differences in gender, age, largest
diameter of stones, residence time among groups (P>0.05). The
results are shown in Table 1.

Group

PCNL group (66)

UPL group (65)

UHLL group (65)

f/χ2

P

Gender (n)

Male

42 (63.64%)

39 (60.00%)

43 (66.15%)

0.54

0.77

Female

24 (36. 36%)

26 (40.00%)

22 (33.85%)

Complicated with underlying diseases (n)

18 (28.13%)

13 (20.63%)

15 (24.59%)

0.96

0.62

Age (y)

40.9 ± 8.4

39.2 ± 6.6

42.0 ± 7.4

2.30

0.10

Largest diameter of stones (mm)

16.7 ± 4.1

18 ± 5.4

17.4 ± 3.2

1.48

0.23

Residence time (w)

25.9 ± 4.7

24.5 ± 5.0

24.2 ± 3.7

2.67

0.07

Table 1. Comparison of 3 groups’ general data (x̄ ± s, n (%)).

Comparison of 3 groups’ operation conditions

There was no connecting open surgery in three groups. The
operation time of PCNL group was significantly shorter than
that of UPL group and UHLL group (P<0.05). The hospital
stays of PCNL group was significantly longer than that of UPL
group and UHLL group (P<0.05). Decline of intraoperative
hemoglobin of PCNL group was significantly larger than that
of UPL group and UHLL group (P<0.05). The successful
lithotripsy rate of PCNL group was significantly higher than
that of UPL group and UHLL group (P<0.05). There were no
significant differences of these indicators between UPL group
and UHLL group (P>0.05). The results are shown in Table 2.

There were no deaths in 3 groups in the perioperative period.
Procedure-related complications include ureteral injury, pyelic
laceration, postoperative hematuria and so on. All
complications were successfully controlled after proper
treatment. Ureteral stricture was founded in UPL group at the 5
w after operation when DJ catheters were pulled out, but
without any major complications. The total complication rates
in PCNL group, UPL group and UHLL group were 16.67%
(11/65), 9.23% (6/65), and 12.76% (8/65) respectively. There
were no significant differences of incidence of complication
among three groups (P>0.05). The results are shown in Table
3.

months of follow-ups were performed after operation. PCNL
group, UPL group, UHLL group have 1, 12, 9 cases
respectively without stones expulsion clearly, the stone
discharge rates were 98.48% (65/66), 81.54% (53/65), 86.15%
(56/65) respectively, there were significant differences among
three groups (χ2=10.11, P=0.01). There into, PCNL group was
significant higher than UPL group (χ2=10.52, P=0.00) and
UHLL group (χ2=7.06, P=0.01). PCNL group, UPL group and
UHLL group have 2, 4, 3 cases respectively with stone
recurrence. The recurrence rates of each group were 3.03%
(2/65), 6.15% (4/65), 1.56% (1/65) respectively, there were no
significant differences of recurrence rate among three groups
(P>0.05).

Discussion

Ureter is divided into upper, middle, and under section. There
are three strictures in the whole Ureter. It is easy to be
impacted to the strictures of ureter when kidney stones are
excreted down through the urine, large diameter stones (more
than 10 mm) are stranded easily in the upper ureter, which
results in hydronephrosis, renal damage [13]. The research
showed that over 80% of ureteral calculi were caused by
kidney, which include kidney stones or landing fragments of
stones after extracorporeal shock wave [14,15]. Upper ureteric
calculi occur in young adults, which is common in patients
aged 20-40 [16]. There are two main factors as follows which
cause upper ureteric calculi [17,18]: (1) Crystal volume
increased in the urine. In special cases, the increasing
metabolism of crystals in body leads to increasing crystals in
the urine. The crystals can further, form precipitation and
stones at last. Besides, partial metabolic disorders can also
produce stone. For example, excretion of uric acid is increased
by purine metabolism disorder, which is liable to cause uric
acid calculi. (2) The change of urine’s physicochemical
environment. The crystals tend to form the stones when the
abnormal changes of urine’s physicochemical environment as
PH and the solute types.

The conventional treatments of upper ureteric calculi include
symptomatic treatment, Chinese medicine treatment and
lithotripsy. Symptomatic treatment process the methods of
local injection with analgesics, hot compress or indomethacin
suppository anal applying; calculi discharge with Chinese
medicine is quite limited, which is applicable for patients
whose stones is <1 cm in diameter, elliptical, smooth and no
hydronephrosis on pyelograghy [19]. Endourological
lithotripsy locates a stone mainly under endoscopic, the calculi
is splintered by shock wave and laser to achieve the purpose of
lithotripsy and lithodialysis, which have better curative effects
on upper ureteric calculi as comparing with conservative
treatment.

Because the position of the upper ureteric massive calculi is
special, the calculi are liable to be impacted, accompanied by
infection and renal damage. Mere symptomatic treatment and
Chinese medicine treatment will often not alleviate the pain of
patients. The conventional laparotomy has the shortcomings of
large injury and increasing rate of infection after operation. In
recent years, minimally invasive technology has become main
stream. Now UPL, UHLL and PCNL are used for complex
upper ureteric calculi clinically. The features of each surgery
are as follows [20]: (1) PCNL establishes the channel of stone
extraction by making an about 0.5 cm incision on the waist.
The stones are splintered with the help of nephroscope vision.
The effect of PCNL for the elimination of staghorn stone and
upper ureteric calculi is preferable. (2) UPL is widely
promoted in 1990s clinically. The principle is to take the
advantage of the energy arising from compressed air to drive
bullets pulse in shafts of lithotriptor for fragmenting stones
under ureter vision. There is no electric current generation
during the operations. Endoscopic insertion is subjected to
certain limitations for patients with ureteral stricture and
ureteral distortion. (3) UHLL mainly inserts the about 3 mm
slender endoscope into kidney through urinary system. The
stones are splintered by laser energy. UHLL has the
characteristics of small injury, fewer complications, and quick
recovery after operation.

Because of the limitation of vision and instrument operation,
UPL and UHLL cannot smash stone thoroughly and need to
underwent lithotripsy repeatedly, thus lengthen operation time.
PCNL can be manipulated in each direction and fragment stone
thoroughly to increase the stone discharge rate, which is
similar with the result of research [4]. But in Tingfang’s study
[21], the operation time of UHLL was significant lower than
UPL, which is not similar with the result of research. The
reason was possibly that the patients in this research mostly
were middle-aged, while patients in Tingfang’s study were
older, which leaded to the decline of operation tolerance and
long hospital stays. Lijie et al. [22] study the endoscopic
treatment for upper ureteric calculi over 15 mm. The result
showed that reduction of hemoglobin in PNCL is slightly
higher, but the operation time was shortened and the residual
stone rate was lowered. It is believed that URL has the
difficulties in operation, while PCNL is recommended, which
is similar with the result of research.

In conclusion, PCNL has the characteristics of short operation
time and stone expulsion thoroughly as comparing with UPL
and UHLL, which is worthy of further promotion clinically.
However, because of few cases of patients and the short
follow-up, the reliability of conclusion remains to be further
confirming in this research. Long-term recurrence rate need
more follow-up.